Mary Lloyd Ireland, M.D. Associate Professor University of Kentucky Dept. of Orthopaedic Surgery and Sports Medicine Lexington, Kentucky

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1 Common Ankle Injuries: Diagnosis and Treatment Mary Lloyd Ireland, M.D. Associate Professor University of Kentucky Dept. of Orthopaedic Surgery and Sports Medicine Lexington, Kentucky

2 Disclaimer Slide Neither I, Mary Lloyd Ireland, MD, nor any family member(s), have any relevant financial relationships to be discussed, directly or indirectly, referred to or illustrated with or without recognition within the presentation.

3 A good History and Physical is Key

4 Foot and Ankle Function Propulsion Support Flexibility Rigidity Gait mechanics

5 Ankle: Modified Hinge Joint Bony configuration Mortise Circular Pretzel Ligamentous stability ATF and CF laterally Deltoid superficial and deep medially Syndesmosis superiorly

6 Basketball Injury Mechanism

7 Summary of Findings From the National Collegiate Athletic Association Injury Surveillance System on Foot and Ankle Injury.* Sport Game Injuries Relating to the Ankle (%) Game Injuries Relating to the Foot (%) Men s baseball Women s softball Men s basketball Women s basketball Men s football Men s lacrosse Women s lacrosse Men s soccer Women s soccer *in Anderson, RB, Hunt KJ, McCormick JJk, Management of Common Sports-Related Injuries About the Foot and Ankle, JAAOS Sept. 2010, Vol. 18, No 9, Table 1, p. 547.

13 EUA Gross instability, right ankle

14 How I Treat... Control swelling Brace Acutely and during the entire season Proprioception Core Prevent recurrent sprains? Ankle sprain preventable?

16 Can we prevent ankle sprain? Even this simple question Unknown by evidence-based studies. Prevent not proven, but we can lessen severity... Maybe! Bahr R. Can we prevent ankle sprains? In: MacAuley D, Best T, Evidence-Based Sports Medicine. London: BMJ Publishing Company, 2002, p. 481.

17 Bahr R. Can we prevent ankle sprains? In: MacAuley D, Best T, Evidence-Based Sports Medicine. London: BMJ Publishing Company, 2002, p Yes, maybe, but... Assess the study critically. Large-scale randomized trials Prior history of ankle sprains Unit of analysis: Ankles, not players

18 Ankle injury prevention programs Bahr, Roald, Can We Prevent Ankle Sprains?, Chapter 25 in MacAuley D and Best T, Evidence-based Sports Medicine (London: BMJ Books, 2002), Table 25.1, p. 472.

19 Key Messages The preventive effects of taping and bracing have been clearly documented, although the evidence is more convincing for players with previous ankle injury than for healthy athletes. Bahr R. Can we prevent ankle sprains? In: MacAuley D, Best T, Evidence-Based Sports Medicine. London: BMJ Publishing Company, 2002, p. 484.

20 Key Messages Although there are some indications that braces seem to be more effective in preventing ankle sprains than tape, this has not been clearly documented. Bahr R. Can we prevent ankle sprains? In: MacAuley D, Best T, Evidence-Based Sports Medicine. London: BMJ Publishing Company, 2002, p. 484.

21 Key Messages The efficacy of wearing high-top shoes is unclear. There is some evidence that balance training reduces the risk of ankle sprains in athletes with previous injury. Bahr R. Can we prevent ankle sprains? In: MacAuley D, Best T, Evidence-Based Sports Medicine. London: BMJ Publishing Company, 2002, p. 484.

22 Basketball athlete EUA prior to lateral ankle reconstruction

23 Renström, Per and Kannus, Pekka, Management of Ankle Sprains, Operative Techniques in Sports Medicine (Vol. 2, No. 1, January, 1994), pp Figure 2.

Renström, Per and Kannus, Pekka, Management of Ankle Sprains, Operative Techniques in Sports Medicine (Vol. 2, No. 1, January, 1994), pp. 58-70. Figure 9. Fig. 9. Chrisman-Snook procedure (modified Elmslie).

24 Renström, Per and Kannus, Pekka, Management of Ankle Sprains, Operative Techniques in Sports Medicine (Vol. 2, No. 1, January, 1994), pp Figure 9. Fig. 9. Chrisman-Snook procedure (modified Elmslie). (A) Split of peroneus brevis tendon. (B) Mobilized half of peroneus tendon threaded through anterior talocalcaneal ligament (held by sutures) and then through hole in fibula. (C) Completed reconstruction. (D) Modification of original operation...

Renström, Per and Kannus, Pekka, Management of Ankle Sprains, Operative Techniques in Sports Medicine (Vol. 2, No. 1, January, 1994), pp. 58-70.

25 Renström, Per and Kannus, Pekka, Management of Ankle Sprains, Operative Techniques in Sports Medicine (Vol. 2, No. 1, January, 1994), pp Figure 12. Fig. 12. Modified Broström technique. (A) Mobilization of lateral extensor retinaculum. (B) Capsular incision, with small cuff remaining.

26 Renström, Per and Kannus, Pekka, Management of Ankle Sprains, Operative Techniques in Sports Medicine (Vol. 2, No. 1, January, 1994), pp Figure 12. Fig. 12. Modified Broström technique. (C) Trimming of stretched CFL (D) Shortening and reattachment of attenuated ATFL and CFL.

27 Renström, Per and Kannus, Pekka, Management of Ankle Sprains, Operative Techniques in Sports Medicine (Vol. 2, No. 1, January, 1994), pp Figure 12. Fig. 12. Modified Broström technique. (E) Suture of extensor retinaculum over repair.

30 Physical Exam of the Foot and Ankle

32 # YO basketball player Os vesalianum bilateral feet.

33 Os peroneum

34 PAINFUL OS PERONEUM Courtesy UK Radiology 34

35 PAINFUL OS PERONEUM Courtesy UK Radiology 35

36 LATERAL ANKLE PAIN Sprain ATF and/or CF Sinus Tarsi Syndrome Subtalar Joint Arthrosis Fracture Cuboid Subluxation Peroneal Dysfunction

37 Think About Peroneal Tendon Involvement If: Recurrent Ankle Complaints Sprain Not Getting Better Pain, Swelling Higher in Peroneal Tendon Sheath

38 In Acute Ankle Sprain, Assess Peroneal Function

39 Physical Exam of the Foot and Ankle

40 17 YO WM High school Baseball/Football Player C/O Repeated Inversion Ankle Sprains

41 [William Brent Bradley Pre-Op.mpg]

42 PERONEUS LONGUS TENDON TEAR Courtesy UK Radiology 42

43 PERONEUS LONGUS TENDON TEAR Courtesy UK Radiology 43

44 18 YO Female Gymnast Right ankle injury Landed awkwardly doing a back tuck Immediate pain and swelling, right ankle 44

45 Initial X-rays 45

46 Stress tests, L & R ankles 46

47 Dx lateral talus fracture displaced Severe lateral ankle sprain 47

48 Surgery 48

49 49

50 50

51 14 YO Female Soccer athlete Left ankle Acute lateral talar dome fracture Documented by plain films and bone edema on MRI

52 Initial X-Rays

54 1 Month after Initial presentation

55 Talar Dome Fracture-45YO Golfer

56 Osteochondral Talar Lesions Osteochondritis Dissecans Men 3 : 1 Women Medial : Lateral 2 : 1 Etiologies Trauma Vascular Repetitive Loading

57 Mechanism of injury of medial border of the dome of the talus. Berndt, A.L. and Harty, M.: Transchondral fractures of the talus JBJS 41 A:988, 1959

60 Physical Exam of the Foot and Ankle

61 HIGH ANKLE Syndesmotic Sprain Courtesy UK Radiology 61

62 HIGH ANKLE Syndesmotic Sprain Courtesy UK Radiology 62

$Maissoneuve fracture Unstable mortise Don t miss this injury$

63 Maissoneuve fracture Unstable mortise Don t miss this injury Results in fibular nonunion and severe tibiotalar osteoarthritis 63

64 Fractures Maisonneuve Fracture 64

65 65

66 66

67 Stress views external rotation and eversion 67

68 Non-treated Maisonneuve fracture rapid progression DJD non-union fibula 68

69 69

70 A good History and Physical is Key to a Correct Diagnosis Know the anatomy Understand the sport

71 The End Thank You! Mary Lloyd Ireland, M.D. Associate Professor University of Kentucky Dept. of Orthopaedic Surgery and Sports Medicine Lexington, Kentucky

Outline. Ankle/Foot Anatomy Ankle Sprains Ottawa Ankle Rules DDx: The Sprain That Wasn t

Outline. Ankle/Foot Anatomy Ankle Sprains Ottawa Ankle Rules DDx: The Sprain That Wasn t Ankle Injuries Outline Ankle/Foot Anatomy Ankle Sprains Ottawa Ankle Rules DDx: The Sprain That Wasn t Anatomy: Ankle Mortise Bony Anatomy Lateral Ligament Complex Medial Ligament Complex Ankle Sprains